We are proposing an innovative strategy to reduce fragmentation and improve the quality of care for a population of low income older adults with multiple chronic conditions and high health care costs. Prior studies have hypothesized that if the preventive care and ambulatory care for vulnerable older adults could be improved then disability, hospitalizations, nursing home placements, and costs could be reduced. Furthermore, recent studies have suggested that disparities in health outcomes among poor urban older adults might be reduced through efforts to improve the underdiagnosis and undertreatment of common geriatric syndromes. The most powerful interventions to achieve quality improvement for older adults involve system-level changes rather than interventions targeted at individual providers. The specific aim of this proposal is to conduct a four-year randomized controlled clinical trial to test the effectiveness of a collaborative model of team care as compared to usual care in improving functional outcomes among community-dwelling low-income older adults. This collaborative model of team care, Geriatric Resources for Assessment and Collaborative Care of Elders (GRACE) builds on the growing body of geriatric health services research suggesting that coordinated care across the continuum of care may improve outcomes for patients with chronic illness. The proposed intervention involves a geriatric nurse practitioner and a geriatric social worker caring for the vulnerable older adult in collaboration with the patient's primary care physician and in consultation with a geriatric specialty team. The specific components of GRACE mirror those recommended in recent reviews: a) specific targeting of elders at risk; b) availability of collaborative expertise in geriatrics; c) integration of the program into primary care; d) coordination of care across all sites of care; e) integration of data systems that support physician's practice and facilitate monitoring of pertinent clinical parameters; and f) institutionally endorsed clinical practice guidelines. We are hypothesizing that, compared to usual care, patients enrolled in the intervention will have: greater independence in activities of daily living, better health status scores, fewer nursing home days, and fewer hospitalizations over 2 years of follow-up.